Provider Demographics
NPI:1619192614
Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS PA
Entity Type:Organization
Organization Name:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS PA
Other - Org Name:ST AUGUSTINE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:2520 US HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6194
Mailing Address - Country:US
Mailing Address - Phone:904-797-4833
Mailing Address - Fax:904-797-7128
Practice Address - Street 1:2520 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6194
Practice Address - Country:US
Practice Address - Phone:904-797-4833
Practice Address - Fax:904-797-7128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMFORTABLE CARE DENTAL HEALTH PROFESSIONALS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-16
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 73631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty